AMITY HEALTH

MEMBER REIMBURSEMENT CLAIM FORM

PO Box 13883, Dubai, United Arab Emirates, Tel: +971(0)42999833, Fax: +971 90 042999822
www.amity.ae

SECTION A: MEDICAL PROVIDER DETAILS

Provider Name Provider License No

SECTION B: PATIENT DETAILS

Patient Name Patient Mobile No
(as per card)

Card Number Patient Patient

File # DOB D D / M M / Y Y Y Y
SECTION C: CLAIM DETAILS
To be completed by attending Physician Pre-Authorisation No
Please tick: Outpatient Inpatient Emergency? Yes No (if applicable)
Chief Complaint What date did the patient
and Symptoms first feel same/similar
symptoms?
Significant Signs D D / M M / Y Y Y Y
Other Conditions
Date of this visit:
Diagnosis D D / M M / Y Y Y Y

MANDATORY: ICD Code (please tick) ICD9 ICD10 (See Amity Reference Guide)
Principal Code 2nd Code 3rd Code 4th Code
Please tick where appropriate
Congenital Chronic RTA Psychiatric Others (please specify)
Check-up Acute Infertility Work-related Vaccination Pregnancy/Indicate LMP:

SECTION D: PROPOSED MEDICAL MANAGEMENT PLAN

Suggestive line(s) of management: Kindly list the recommended investigations and/or procedures
TYPE OF
CODE CODE USED DESCRIPTION / SERVICE QUANTITY TYPE COST

Anticipated Management Plan: TOTAL COST

Referral Doctor’s Name License

(if patient has been referred) No
PATIENT DECLARATION
I declare that I am the patient, patient's parent or guardian (if patient is under 16 years of age) and that all information provided in the claim form is
to the best of my knowledge true and correct. This declaration gives Amity the permission to get all information about my claim including, but not
limited to, my current medical and previous medical providers/physician, pharmacy or any other person who has provided medical services to me or
my dependants. I agree that a copy of this consent shall have the validity of the original.
Signature Date D D / M M / Y Y Y Y
MEDICAL PRACTITIONER DECLARATION
I declare that all information mentioned is correct and that the medical services shown on this form were medically indicated and necessary for the
management of this case.
Name Tel/Fax Signature
and Stamp
License Date
No D D / M M / Y Y Y Y